Download THE IMPACT OF OPERATIVE FLUIDS ON THE PREVENTION OF POSTOPERATIVE AMBULATORY SURGERY

THE IMPACT OF OPERATIVE FLUIDS
ON THE PREVENTION OF POSTOPERATIVE
ANESTHETIC COMPLICATIONS IN
AMBULATORY SURGERY
- High Dose vs Low Dose ABDUL-HAMEED C HOHEDRI*, M ASOOD MATIN
AND A BBAS K HOSRAVI
Abstract
Background/Aim: Adequate control of postoperative (postop.)
nausea, vomiting, dizziness and thirst, and early return to normal activity
are important anesthetic goals in the context of ambulatory surgery. This
study, investigated the impact of different preoperative fluid therapies or
regimens on preventing postop. nausea, vomiting, dizziness and thirst.
Materials and Methods: In a prospective randomized double-blind
study, from June 2002 to November 2003, two hundred ASA grade I-II
ambulatory surgical patients received 20 ml/kg of intravenous isotonic
electrolyte solution (0.9% sodium chloride) (group A) or 2 ml/kg of same
(group B) (n = 100 in each group), over 30 minutes before induction of
anesthesia. A standard general anesthetic technique and postop. analgesia
were used throughout the operation. Adverse postop. outcomes (nausea,
vomiting, dizziness, and thirst) were assessed at 30 and 60 minutes
postop. and at discharge.
From Department of Anesthesiology, Nemazee Hospital, Shiraz University of Medical Sciences,
Shiraz, Iran.
* Corresponding Author: Chohedri A.H, MD. Department of Anesthesiology, Namazee Hospital,
P.O. box: 71345, Shiraz, Iran. Tel: +98 (711) 229-1169, Fax: +98 (711) 230-7072, E-mail:
[email protected].
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ABDUL HAMEED CHOHEDRI ET. AL
Results: The incidence of postop. vomiting and thirst significantly
decreased in group A compared to group B (p = 0.014 and p = 0.029,
respectively). There was no difference in the incidence of nausea and
dizziness between the two groups.
Conclusion: We conclude that preoperative high dose hydration (20
ml/kg bolus) can efficiently decrease the incidence of postop. thirst and
vomiting within the first 60 minutes, it was superior to low dose
hydration and therefore, we recommend it in ambulatory surgeries.
Key words: Ambulatory surgery, vomiting, nausea, thirst, dizziness,
preoperative hydration, postoperative anesthetic complications,
antiemetic.
Introduction
In the past decade dramatic increase in ambulatory surgery has been
observed. In recent years, up to 80% of patients in the United States are
being admitted on the day of surgery1. Ambulatory surgery and anesthesia
can offer a large number of advantages to patients, health care providers
and hospitals. However, it is unfortunately associated with a number of
unpleasant postoperative experiences such as pain, nausea, vomiting,
dizziness and thirst. Short acting anesthetic agents have provided major
advantages in the field of acute pain. However, despite the availability of
new antiemetic agents, the incidence of other postoperative adverse
effects, especially nausea and vomiting, has remained significantly
unchanged2.
Nausea and vomiting are the most common and distressing
symptoms associated with surgery and one of the most common reasons
for poor patient satisfaction-rating, in the postoperative period3.
Currently, the overall incidence of postoperative nausea and vomiting for
all surgeries and patients is estimated to be 25-30%4. Postoperative
nausea and vomiting may be associated with serious complications such
as dehydration, electrolyte disturbances, wound dehiscence, pulmonary
aspiration and esophageal rupture leading to a delay in post-anesthesia
recovery room discharge and thereby increasing medical costs5.
IMPACT OF OPERAT. FLUIDS PREVENTION POST. COMP. AMB. SURG.
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Recent studies have demonstrated that preoperative hydration of
patients undergoing in-patient and out-patient surgeries can decrease the
incidence of postoperative adverse outcomes4,6-8. However, the isotonic
solution used in those studies are not easily accessible to our patients and
in our setting.
The aim of this study was to investigate the efficacy of preoperative
hydration with 0.9% sodium chloride (an easily available fluid in our
setting) in decreasing and preventing postoperative nausea, vomiting,
thirst and dizziness.
Materials and Methods
In a prospective randomized double-blind clinical trial, from June
2002 to November 2003, two hundred ASA grade I-II ambulatory surgical
patients, who had been referred for surgery to the educational hospitals of
Shiraz University of Medical Sciences, were studied. A written informed
consent was obtained from each patient and the Shiraz University of
Medical Sciences Research Committee had approved the study.
Patients’ age ranged from 17 to 60 years and they were scheduled
for general, orthopedic and gynecologic surgeries. Patients who gave
positive history of cardiovascular diseases, diabetes, preoperative history
of nausea, vomiting or dizziness and motion sickness, were excluded from
the study. Demographic characteristics, type of surgery and history of
drug consumptions, were recorded.
Two hundred patients (77 males, 123 females) were randomly
allocated to two equal groups of 100 each. The first group (group A)
received 20 ml/kg of intravenous 0.9% sodium chloride (sodium chloride,
154 mEq/L). The second group (group B) received 2 ml/kg of the
solution. The fluid was given as bolus over 30 minutes before induction
of anesthesia.
A standard general anesthetic technique and postoperative analgesia
were used throughout the operations. Induction was done with diazepam
(0.1 mg/kg) and morphine (0.15 mg/kg). Endotracheal intubation was
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accomplished with 1.5 mg/kg of succinylcholine and 4 mg/kg Pentothal.
Anesthesia was maintained with a mixture of oxygen (50%) and nitrous
oxide (50%) with end-tidal halothane (0.5 MAC) in a semi closed circle
system. Atracurium (0.3 mg/kg IV) was used for muscle relaxation.
Neuromuscular block was reversed with neostigmine (50 g/kg) and
atropine (25 g/kg). All patients received a maintenance IV fluid therapy
of isotonic saline, 1 ml/kg/hour, throughout surgery and during the
postoperative period. If more fluid was needed, due to hypotension or
bleeding, the patient was excluded from the study.
Blood pressure, heart rate, oxygen saturation, electrocardiogram,
tidal volume, end-tidal CO2, end-tidal concentration of the inhaled
anesthetic, airway pressure, and minute volume, all were monitored.
Adverse postoperative outcomes (nausea, vomiting, dizziness, and
thirst) were assessed by an anesthesiologist, at 30 and 60 minutes
postoperatively and at discharge. Nausea was defined as subjective
complain of nausea with increase in salivary secretion; vomiting, as active
retching and active vomiting of gastric content; dizziness as subjective
complain of faintness and inability to sit in bed or walk without support;
and thirst, as a desire to drink and dry mucosa of the mouth. The
anesthesiologist assessing the adverse outcomes, the attending
anesthesiologist, and recovery room nurses were all blind to the patients’
allocation group and the amount of preoperative fluid therapy they had
received.
All data were analyzed and computed by SPSS (Chicago, IL)
software, version 10.0, and Microsoft EXCEL (Microsoft, Redmond,
WA) software. Data are expressed as mean  standard deviation (SD) and
95% confidence interval (CI) are also given when essential. The
association between variables was assessed with Student’s t-test; Fisher’s
exact, 2 test and Mann Whitney U-test. p values less than 0.05 were
considered statistically significant.
Results
Among the two hundred patients (77 males, 123 females) enrolled in
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the study, 66 patients had gynecological operations (vaginal cyst removal,
IUD removal, and cervical polyp excision), 67 orthopedic (bone biopsy,
pin removal, removal of bone exostosis, and treatment of carpal tunnel
syndrome), and 67 general surgical operations (inguinal herniorrhaphy,
breast mass biopsy, epigastric hernia repair, lateral sphincterectomy and
hemorrhoidectomy).
Demographic characteristics, type of operation, and duration of
operation are shown in Table 1. There was no significant difference
between the two groups in demographic characteristics (age, weight and
sex), type of operation, or ASA classification. Additionally, there was no
significant difference between them in the amount of anesthesia given and
the duration of anesthesia. Total amount of fluid infused in group A (High
dose fluid therapy) was 1197  25 ml and in group B (low dose fluid
therapy) 171  22 ml.
Table 1
Demograpic characteristics, type of operation, and duration of operation
of the 200 patients.
Group A
Group B
High dose
Low dose
p
fluid therapy
fluid therapy
value
(n = 100)
(n = 100)
Age (years)
34.58  12
34.8  11.1
NS
Weight (kg)
57.52  7.9
56.9  8.3
NS
39/61
38/62
NS
Sex (M/F)
Gynecology operation
33
33
NS
Type of
Orthopedic
34
33
NS
operation
procedures
General surgery
Duration of operation (min)
ASA grade I/II
32
35
NS
63.55  19
64  18.29
NS
80/20
76/24
NS
NS: not significant; p > 0.05.
The incidence of postoperative thirst significantly decreased at both
30 and 60 minutes postoperative in group A when compared to group B
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(p = 0.029) (Figure 1).
Fig. 1
The incidence of postoperative thirst. Group A, High dose fluid therapy; Group B,
Low dose fluid therapy; 30M = 30 min postop; 60M = 60 min postop; p < 0.05
for 30M and 60M for the two groups using 2 test.
The incidence of vomiting also was lower at all times; however only
in the first 60 minutes it was statistically significant (Figure 2).
Fig. 2
The incidence of postoperative vomiting. Group A, High dose fluid therapy; Group B,
Low dose fluid therapy; 30M = 30 min postop; 60M = 60 min postop; p > 0.05
for 30M; however for 60M p value not significant; using 2 analysis.
The incidence of nausea and dizziness was lower in group A, but the
difference was not significant (p > 0.05; Figures 3 and 4, respectively).
There was no statistically significant difference in the incidence of
IMPACT OF OPERAT. FLUIDS PREVENTION POST. COMP. AMB. SURG.
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adverse effects and the type of operation (p > 0.05).
Fig. 3
The incidence of postoperative Nausea. Group A, High dose fluid therapy; Group B,
Low dose fluid therapy; 30M = 30 min postop; 60M = 60 min postop p value not
significant (p > 0.05) for both 30M and 60M for the two groups using 2 test.
Fig. 4
The incidence of postoperative dizziness. Group A, High dose fluid therapy; Group B,
Low dose fluid therapy; 30M = 30 min postop; 60M = 60 min postop p value not
significant (p > 0.05) for both 30M and 60M for the two groups using 2 test.
Discussion
The incidence of postoperative adverse outcomes, such as thirst,
nausea, vomiting, and dizziness depends on multiple factors; surgical
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procedure, anesthetic technique and the fluid status6,8. Several studies
have been done on the prevention of nausea and vomiting and different
regimens have been suggested2,4-11. However, only limited work had been
done to determine the correlation between preoperative fluid therapy and
the well being of patients in the postoperative period. Cook et al. reported
decrease in the incidence of postoperative adverse effects with fluid
administration, especially when sugar was added to the regimen6.
However the study was not double-blinded. In a prospective doubleblinded randomized study done by Yogendran et al, high-infusion fluid
therapy was compared with low-infusion8. They demonstrated that the
incidence of adverse outcomes, such as thirst, dizziness and drowsiness,
was significantly lower in the high-infusion than in the low-infusion
group at 30 min and 60 min after surgery, at discharge and on the first
postop. day8. Our prospective double-blinded randomized study also
demonstrated that high dose preoperative fluid therapy (20 ml/kg) could
significantly decrease the incidence of thirst and vomiting at 30 and 60
minutes postop.
Postoperative adverse effects are potentially dangerous and
disturbing for patients. They delay early discharge, home readiness and
increase the workload of the nursing staff. Hydration was advantageous in
reducing the incidence of adverse postoperative effects and therefore,
achieving a higher rate of patients’ satisfaction.
Different intraoperative fluid therapy regimens have been suggested.
These different methods have been proposed depending on the type of
surgery. Most studies have suggested administering fluid in order to
obtain a urine output of 1 ml/kg/hour12. However, there has been no
standardized fluid regimen therapy for patients scheduled for ambulatory
surgery.
Yogendran et al had suggested 20 ml/kg based on the daily water
requirement of approximately 30 ml/kg per day8 confirming our finding
that this amount of hydration had significant effects in decreasing
postoperative side effects. This amount of hydration was especially useful
in our patients, as in our setting, ambulatory surgeries are mostly done in
the afternoon and elective operation are done in the morning. Therefore,
IMPACT OF OPERAT. FLUIDS PREVENTION POST. COMP. AMB. SURG.
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our patients had been fasting for more than 12 hours (from 12 midnight
until 1 PM of the next day) and so patients were in a dehydrated
condition.
Our study reveals that alleviating dehydration with adequate fluid
therapy reduced the incidence of postop. thirst and vomiting, within the
first 60 minutes. It is therefore concluded that preoperative hydration (20
ml/kg) for patients who are undergoing general anesthesia in short
ambulatory surgery, is recommended.
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